Woc Fistula Enterocutan - Ledika Alma Novitasari - Profesi Ners

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LEDIKA ALMA NOVITASARI

PROFESI NERS KI
P1337420923151
WOC FISTULA ENTEROCUTAN

Stomach hurts Appendicitis appendectomy The incision wound


is not completely
closed

The incision wound infection


laparotomy
always oozes fluid
(seeps)

Leakage at the Definition


Nutritional Deficit related to suture wound Signs and symptoms
Enterocutaneous fistula (ECF)
excretion of juices food from
the fistula, the absorption 1. Dehydration is an abnormal connection that
capacity is inadequate (D.0019) FISTULA
develops between the
ENTEROCUTAN 2. Malnutrition
intestinal tract or stomach and
3. Diarrhea the skin. As a result, the
contents of the stomach or
Intestinal fluid comes
Stool, pus comes out intestines leak onto the skin.
out through the skin

The complexity of an enterocutaneous


fistula depends on amount of expenditure.
High risk of infection Infection of the
is associated with a.Low: 200 ml/24 hours
suture wound b.Moderate: 200-500 ml/24 hours
reduced power body
c. High: 500 ml/24 hours
resistance, surgical
process (D.0142)
VAC installed with a Impaired skin/tissue Complications that can
Pain around the integrity related to
colostomy bag with a occur in patients with fistula
wound decreased mobility
pressure of 15Kpa (D.0192) enterocutaneous:

a. Malnutrition
Intervention: Pain Management b. Dehydration
Chronic Pain associated Disturbed sleep (I.08238)
with mucosal irritation, patterns related to pain c. Skin problems
inflammatory processes (D.0055) The results criteria to prove that
the level of pain has decreased d. blood poisoning
(D.0078)
are:
1. Reduced pain complaints
Intervention: Nutrition Intervention:Infection 2. Feelings of depression Intervention: Sleep Support
Management (I.03119) Prevention (I.14539) decrease (I.05174)
3. Grimacing decreases
The outcome criteria to The outcome criteria to The results criteria to prove that
4. Decreased anxiety
prove that nutritional prove that the infection rate the level of sleep disturbed has
5. The ability to complete
status has improved are: is decreasing are: decreased are:
activities increases
nutritional status improves
1.Fever decreases Pain Levels Decreased L.08066
1. Complaints of difficulty
1. The portion of food 2.Redness decreases sleeping have decreased
consumed increases 3.Pain decreases 2. Complaints often decrease
2.Body weight improves 4.Swelling decreases 3. Complaints of dissatisfaction
3. Body mass index (BMI) 5. White blood cell levels with sleep have decreased
Intervention: Skin Integrity
improves L.03030 improve 4. Complaints about changing
Treatment (I.11353)
Infection Rates Decreased sleep patterns have decreased
L.14137 The result criteria to prove that the 5. Complaints of not getting
level of impaired skin integrity has enough rest decreased
decreased are:
Improved Sleep Patterns L.05045
1. Decreased tissue damage
2. Decreased skin layer damage
Skin/tissue integrity improves
L.14125

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